Marilyn Anne

Application of Bureaucratic- Caring Theory to Nursing Practice

The application of this theory is based on a hospital setting wherein these stories are personally experiences of the nurses shared with the author while she is still working implementing a caring model for professional nursing practice.

Marilyn A. Ray, RN, PhD, CTN-A, Professor Emeritus, Florida Atlantic University

-          renowned nursing educator and researcher of caring in complex health care systems and transcultural nursing.

-          Dr. Ray is an advanced  transcultural nurse committed to the development and progress of transcultural caring in nursing worldwide.

-          She is well known for her theory of bureaucratic caring, which integrates  knowledge of human caring within complex technological, economic, legal, and political systems in hospital organizations.

-          Previous awards include the Christine E. Lynn Eminent  Scholar Chair in Nursing, Florida Atlantic University; Yingling Visiting Scholar, Virginia Commonwealth University; Visiting Lecturer, University of Alberta, Canada, Clinical Sciences Division. Ray attended seminars at the Kennedy Institute of Ethics, Georgetown University.

-          She also studied with Dr. F. David Peat in Pari, Italy, the distinguished physicist in the sciences of complexity. Other fellowships include the Ministry of Health of Ontario and visiting scholar positions in universities in Australia. She has held faculty positions at the University of Colorado, College of Nursing; the Union Institute, Cincinnati; McMaster University, Hamilton, Canada; the University of California, School of Nursing; and the University of San Francisco,School of Nursing.

-          From 1967 to 1999, Dr. Ray served as an officer in the United States Air Force, beginning first with the Wyoming Air National Guard followed by the United States Air Force Reserve. She held the rank of Colonel from 1984 to her retirement in 1999. During her military career, Ray held many diverse positions—flight nurse, educator, researcher, and administrator in many USAF Commands across the United States. She attended the Marshall Space Center to support the potentialrole of nursing in space. During the last 8 years of her career she was a researcher at the USAF School of Aerospace Medicine, Brooks Air Force Base, Texas.

-          Ray recently completed a book titled Transcultural Caring Dynamics in Nursing and Health Care. She edited one book with Dr. Jean Watson and has numerous chapters and peer-reviewed articles in many journals. Her work is translated into different languages.

-          She has over 20 funded research grants totaling almost one million dollars, and presents nationally and internationally, the most recent at the World Universities Forum in Davos, and universities in Lausanne, Switzerland. Ray recently visited the WHO, and the International Council of Nurses in Geneva, Switzerland, sharing knowledge and her experience of transcultural nursing, theory and research, and a vision for the future of nursing within the complex global environment.

INTRODUCTION 

Health care organizations are hierarchical and show management system methods that show some degree of command, authority, and control for effective functioning. Hospitals tend to be bureaucratic; that is, they are not only places for the care of the sick, but they also are integrated technical-politico-economic and legal organizations. Revolutionized health care environments have raised questions associated to patient care. How are political, economic, legal, and technological caring decisions made? How is spiritual caring fostered? How can ethical caring be the grounds on which moral decisions are made? What new policies must be designed to enhance the human perspective in corporate policy, and how will these principles and policies guide actions? The introduction of the Theory of Bureaucratic Caring on the corporate background will necessitate a system shift from a narrow to a broad focus where management and caring views can exist side by side and realistically represent the transformation of health care organizations to benefit humankind As the twenty-first century is developing, nursing in multifaceted organizations has to advance as well.  Bureaucratic caring theory encourages us to envision how a new model may assist us in comprehending how nursing can be practiced in contemporary health-care setting by illustrating the importance of spiritual and ethical caring in relation to organizational cultures. , such as political, economic, legal and technological aspects of hospital organization.

	MAJOR CONCEPTS OF THE THEORY
Concept	Definition
Caring	Is defined as a complex, transcultural, relational process, grounded in an ethical, spiritual context. Caring is inevitable within a culture or society, such as, personal culture, hospital organizational culture, and society culture.
Spiritual-ethical caring	This pertains a holistic integration of the body, mind and spirit. Spiritual-ethical caring for nursing focuses on the facilitation of alternatives for the good of others can or should be attained.
Education	Education both formal and informal programs make use of audiovisual media to disseminate information, and also other forms of teaching and relaying information are factors related to defining care.
Physical	This factor is related to the physical state of being, which includes, biological and psychological patterns. The reason is that, both the human mind and body are interrelated, showing a pattern that influences the other.
Socio-cultural	Social and cultural aspects are factors related to ethnicity and structures of the family; intimacy with friends and family; communication; interaction and support with a social group, community and society.
Legal	Definition of caring in terms of legal factors are responsibility and accountability; rules and principles as guidance of one’s behavior, such as policies and procedures; informed consent; rights to privacy; malpractice and liability issues; client, family, and professional rights; and the practice of defensive medicine and nursing.
Technological	Factors relating to technology such as non-human resources, like the use of machines to sustain physiological well-being of the patient, diagnostic investigations, pharmaceutical agents, and also the knowledge and skills required to operate the resources.
Economic	Related factors of the definition of caring include money, budget, insurance systems, limitations, and guidelines imposed by managed care. Caring as an interpersonal resource should be considered like goods, money, and services.
political	How nursing is viewed within a healthcare administration is influenced by political and the power structure. This included the communication patterns, decision making within the organization, role gender stratification among nurses, physicians, and administrators; union activities including negotiation and confrontation; government and insurance company influences; uses of power, prestige, and privileged are, in general, competition for scares human and material resources.

Ray’s theory focuses on caring in organizations (e.g. hospital) as cultures. The theory suggests that caring in nursing is contextual and is influenced by the organizational structure. She emphasized the interconnectedness of nursing care and health care organizations. The theory emphasizes the holistic nature of an organization rather than simple cause-effect relationships of individual actions. Spiritual-ethical caring by nurses, the ultimate goal of which is the promotion of well-being through caring, has a positive effect on health care organizations and can become an economic resource.

-  Example: ICU had a dominant value of technological caring (i.e., monitors, ventilators, treatments), Oncology unit had a value of a more intimate, spiritual caring (i.e., family focused, comforting, compassionate). Furthermore, the meaning of caring was further influenced by the role and position a person held. Staff nurses valued caring in terms of its relatedness to client, while administrator valued caring as system related.

- Spiritual –ethical caring influences each of the aspects of the bureaucratic system (political, legal, economic,, educational, physiologic, social-cultural, and technological) 

PROPOSITION/IDEA

“Caring in nursing is contextual and is influenced by organizationalstructure.” Spiritual-ethical caring for nursing  does  not  question whether or not to care in complex systems, but intimates how sincere deliberations and ultimately the facilitation of choices for the good of others can or should be accomplished

Strengths and Weaknesses

One of the major strengths in Ray's Theory of Bureaucratic Nursing is that its assumptions can be highly applicable in the modern nursing profession. With the fast advances in technology and healthcare, Nursing today has been more elaborate. There have been several fields such as oncology nursing, infection control nursing, gerontologic nursing and many more. Nurses have also assumed administrative positions such as nurse supervisors and chief nurse. These different fields if nursing may affect the nurse's interaction and view on patient care. Ray's theory suggests that caring in nursing is contextual and is influenced by the organizational structure. For instance, a staff nurse who is primary involved in direct nursing care may have a different caring approach to a patient as compared to his chief nurse who is more concerned in the nursing system in the hospital.

Also, the Bureaucratic Theory has never lost the heart of the profession. Ray states that care for a patient may be affected by political, legal, economic, educational, physiologic, socio-cultural and technological factors. But these factors are influenced by spiritual-ethical caring. In this theory, the nurses, especially those in the administrative position serve two masters. First is the patient, second is the organization the nurse is working for. As part of the administrator, the nurse is responsible to make decisions that will be beneficial for the organization (this is the politics, legal and economics factors). But, as a nurse, whose primary role in patient-care, she is also in the position to make decisions to ensure that quality of care is given to the patient.

However, one limitation is that the theory is focused on nursing in the hospital. the organization mentioned in the theory pertains to a hospital administration. Hence, this theory is less flexible and may not be applicable to other fields of nursing like public health.

Nursing Situation: Registered Nurse

It started when Joseph, 84 year- old white male, was admitted. He was found by a neighbor laying in the kitchen floor. Upon admission the RN assess the patient and found out that his left arm and his left leg are weak. When the RN ask him, he was reluctant answering the questions. He was asked by this RN " What is most important to you about this time? Joseph explained that it is the second death anniversary of his wife and he wanted to go to the cementery to pray with her.

The RN recognized that this was not possible.She and her colleaugues,  the other health care nursing assistants came up with the idea to help Joseph meet his spiritual needs. Some of them went to pick up the chaplain, one nursing assistant  went to buy flowers from the gift shop. When the chaplain arrived, they went to the room and offered a prayer and a song. Karen,his nurse, offered to accompany him to the cementery to place flowers in his wife's grave.

The following day, he was asked by Karen, "What do you remember about your wife?". He replied, "That her wife is a caring perosn and it was difficult for him to see her suffer at the bed. You see, we never sign any papers, and the doctors put a lot of tubes in her at the end.I don't want to live or be like that."

Karen uphold Joseph's personal struggle and he asked him if he would want to have an advance directive. She explained to him that this will allow him to put his wishes in writing and from a legal perspective the nurse and physicians must honor and respect his wishes. Later in the afternoon, the paper was finished.

During the night shift, Joseph experience an increased blood pressure and difficulty of breathing. He was transferred to the Intensive CAre Unit and placed on a intravenous medication for blood pressure controlled. When he was stabilized already, he was asked by his nurse"What can I do for you?". He replied that he wants to see his children and he instruct the RN to look over the paper. He said, " I don't want any tubes in me if I will breath".

At the middle of the night, he experienced more difficulty of breathing. The physician decided that it is time to hook him in the inspirator.  Joseph weakly replied, " No tubes". Nurse Dianne, who is on duty that night inform the physician regarding the paper that the patient signed. After reviewing the documents, the doctor honored the request. The children decided to transfer Joseph from Intensive Care Unit to a Private room. They sang and they took turns holding Joseph's hand. He died the following day in his bed, accompanied by his family.

References:

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Parker, Marilyn E. Nursing Theories and Nursing Practice. Second Edition.  Boca Raton, Florida. F.A. DAVIS COMPANY • PHILADELPHIA

K.Scott (June 12, 2007). Nurse Practitioner: Patient Care or Administator 

http://www.bod.com/index.php?id=3435&objk_id=4031074. http://media.axon.es/pdf/92311.pdf 

RNPedia.com (n.d). Fundamentals of Nursing: Caring 

http://marilynray.com/wp-content/uploads/2012/10/Theory-of-Bureaucratic-Caring.pdf